BIPOLAR DISORDER AND VIOLENCE

Transcription

1 Psychiatric Quarterly, Vol. 72, No. 2, 2001 BIPOLAR DISORDER AND VIOLENCE Theodore B. Feldmann, M.D. Violent behavior presents many social, legal, and clinical problems. A number of models have been developed to explain violence, representing a variety academic disciplines and theoretical orientations. Unfortunately none of these approaches have led to a comprehensive understanding of violence and aggression. The issue of violence is particularly perplexing in connection with the role of psychiatric disorders as contributing factors. Several psychiatric conditions, including bipolar disorder, have been implicated with increased rates of violent behavior. This paper examines various models of violence, influences on violent behavior, and violence associated with psychiatric disorders. Particular attention is devoted to the connection between bipolar disorder and violence. KEY WORDS: bipolar disorder; violence; aggression; demographics of violence; prediction of violence. The understanding of violent behavior presents many challenges for psychiatrists. Models to explain violent behavior have reflected a variety of theoretical orientations and have all been influenced by social and cultural variables. Biological views have focused on genetic or constitutional inferiority, body type, studies of twins and adoptees, chromosomal Theodore B. Feldmann, M.D., is with the Department of Psychiatry & Behavioral Sciences, University of Louisville School of Medicine. Address correspondence to Theodore B. Feldmann, M.D., Department of Psychiatry & Behavioral Sciences, University of Louisville School of Medicine, Louisville, KY /01/ $19.50/0 C 2001 Human Sciences Press, Inc.

2 120 PSYCHIATRIC QUARTERLY defects, EEG abnormalities, central and autonomic nervous system dysfunction, and neurotransmitter abnormalities. Sociological approaches to violence stress the role of adverse social conditions in the genesis of aggression. Factors such as poverty, illiteracy, drugs, and disintegration of the family are seen as causative. Psychodynamic formulations attempt to understand violence and aggression through an examination of early life experiences and relationships, and their connection to unconscious thought processes and motivations. Issues related to sexuality, aggression, and faulty internal object representations have been described. This school has contributed much to our current understanding of the psychopathic personality. While all of these views are useful, each has inherent weaknesses, arguing for continued theoretical research on violent behavior. Understanding violence and its association with psychiatric disorders is of importance for a variety of reasons. One example is the prediction of dangerousness, which has become more important since the Tarasoff decision imposed a duty on mental health professionals to warn and protect potential victims who may be at risk for violence committed by psychiatric patients. The rates of violent crime in the United States, although decreasing in recent years, continue to bring increased attention to the prediction of violence in criminal personalities. Cases of political assassins, such as John Hinckley and others with a history of mental illness, have likewise served to stimulate an examination of violence in certain personalities. The issue of treatment and rehabilitation of violent offenders is another area where an understanding of the antecedents and determinants of aggression is essential. Finally, violent behavior associated with street gangs, drug use, cults, and terrorism has generated intense interest in the study of violence and aggression. This paper presents an overview of violence and the factors that influence its occurrence. Specific attention is devoted to the relationship between violence and psychiatric disorders, in particular bipolar disorder. DEMOGRAPHICS OF VIOLENCE A variety of factors have been associated with crime and violence. One of the most comprehensive studies on the demographics of violence was conducted by Monahan in 1986 (1). This study found that violent behavior in adults tends to peak in the late teens and early 20s. In general, violence is more common among men than women. Lower socioeconomic classes are associated with higher rates of violence than other groups.

3 THEODORE B. FELDMANN 121 Monahan also found that a variety of other factors are associated with violence. Persons with low IQs have a greater propensity for violence. Substance abuse predisposes to violence. Violence is greater among persons with less education. Residential and employment instability are associated with higher rates of violence. Each year the Federal Bureau of Investigation (FBI) catalogues crime rates in the United States; the results are published in the Uniform Crime Reports (2). The FBI has found that two million violent crimes are committed each year. The homicide rate in the United States is 9.3 per 100,000 population. Social and cultural factors exert a strong influence on violence. For example, FBI data reveals that a middleclass white male has one chance out of 131 of being murdered. On the other hand, African-American men living in inner-city areas have one chance in 21 of being a murder victim. The FBI also records the relative frequency of violent crime in the United States. According to their statistics, one murder occurs every 22 minutes, one forcible rape occurs every five minutes, and one aggravated assault takes place every 28 seconds. INFLUENCES ON VIOLENCE A number of factors exert an influence on the commission of violent acts, making the understanding and prediction of violence a difficult endeavor. In order to make a well-informed assessment, violence must be viewed as an interaction of personality traits and various stimuli in the environment. In general, a past history of violence is the best predictor of future dangerousness. It is insufficient, however, to know only an individual s history of violence. Careful assessment must also be given to how a particular situation is affecting a person. It should also be remembered that it is much easier to predict imminent violence in a given person than it is to predict future violence. The presence of on-going psychosocial stressors increases the likelihood of violence. Frequent exposure to violence, either in an active or passive manner, increases the risk of violent behavior. A history of physical or sexual abuse also predisposes to violence. The degree of social approval of violence in ones cultural and family environment also exerts a strong influence on the emergence of violent or aggressive behavior. An individual s ability to develop alternative strategies of conflict resolution will also influence violence. Finally, the availability of weapons exerts a strong influence on violent behavior. Table 1 summarizes the personal and situational factors that contribute to violent behavior.

4 122 PSYCHIATRIC QUARTERLY TABLE 1 Personal and Situational Factors Contributing to Violence 1. Statements about violence and previous violent behavior. 2. History of mental illness, drug, or alcohol abuse. 3. Legal history, with special attention to violent crimes. 4. Socioeconomic status and employment stability. 5. The degree of social approval of violent behavior in a person s cultural and family environment. 6. Availability of weapons. 7. Current mental status. 8. Fantasies about aggressive behavior. 9. Delusions of a paranoid, grandiose, or aggressive nature. 10. Auditory hallucinations, especially of a command type. 11. Ongoing stressors in other areas of the person s life. 12. The degree of acknowledged personal responsibility for creation of the conflict situation. 13. Ability to discuss or develop strategies for conflict resolution. 14. Degree of appreciation for consequences of verbalized threats. TYPES OF AGGRESSION An understanding of violence also requires an appreciation of the fact that distinct types of aggression occur. There are two primary types of violence: affective aggression and predatory aggression (3). These two categories have distinct neuroanatomical pathways and are controlled by different sets of neurotransmitters. Affective aggression is the result of external or internal threatening stimuli. These stimuli evoke an intense activation of the autonomic nervous system and are accompanied by threatening vocalizations and attacking or defensive postures. Many of the pathways associated with affective aggression are closely tied to the spinothalamic tract and the periaquaductal gray matter of the brain. The characteristics of affective aggression (see Table 2) include an intense sympathetic arousal of the autonomic nervous system. There is a strong subjective experience of conscious emotion, consisting primarily of anger. If violence occurs in connection with affective aggression, it is reactive and immediate. An internally or externally perceived threat is present in nearly all cases. The goal of affective aggression is threat reduction. Rapid displacement of the target of aggression occurs. A time-limited behavioral sequence is seen, with the anger and aggression rapidly dissipating. Violent behavior is prefaced by public

5 THEODORE B. FELDMANN 123 TABLE 2 Characteristics of Affective Aggression 1. Intense sympathetic arousal of the autonomic nervous system. 2. Subjective experience of conscious emotion. 3. Violence is reactive and immediate. 4. Perception of an internal or external threat. 5. Goal is threat reduction. 6. Rapid displacement of target of aggression. 7. Time-limited behavioral sequence. 8. Violence is prefaced by public ritual accompanied by verbal threats. 9. Primary affective dimension. 10. Heightened and diffuse sensory awareness. 11. Loss of ability to differentiate who people are (i.e., a blind rage ). 12. Possible loss of reality testing. 13. Lowered self-esteem. ritual accompanied by verbal threats. The person experiences his or her environment primarily on an affective dimension. Heightened and diffuse sensory awareness occurs. There is a loss of ability to differentiate who people are (i.e., a blind rage ). Loss of reality testing may occur. Finally, the individual generally experiences lowered self-esteem following the episode. Predatory aggression, on the other hand, is directed toward the destruction of prey, usually for food gathering in subhuman species (see Table 3). It involves minimal autonomic arousal, little or no vocalization, and no elaborate behavioral rituals. There may be selective suppression of other sensory input and also some species-specific killing patterns (e.g., the hunting behavior of lions, tigers, and other predatory cats). Neuroanatomical pathways appear to project from the hypothalamus into the ventral midbrain tegmentum. The characteristics of predatory aggression include minimal or absent autonomic arousal. There is no conscious experience of emotion. When violence occurs, it is planned or purposeful violence. Aggressive behaviors take place in the absence of a perceived threat. The behavioral goals of the individual are multidetermined and variable, but generally do not include threat reduction. Minimal or absent displacement of the target of aggression is seen; the subject remains focused on the original target. A time-unlimited behavioral sequence is associated with predatory aggression. These behaviors may be preceded or followed by private ritual. The episode is experienced primarily on a cognitive dimension with little or no affective response. The person experiences a

6 124 PSYCHIATRIC QUARTERLY TABLE 3 Characteristics of Predatory Aggression 1. Minimal or absent autonomic arousal. 2. No conscious experience of emotion. 3. Planned or purposeful violence, if present. 4. No or minimal perceived threat. 5. Multidetermined and variable goals. 6. Minimal or absent displacement of the target of aggression; the subject remains focused on the original target. 7. A time-unlimited behavioral sequence. 8. Preceded or followed by private ritual. 9. A primary cognitive dimension. 10. Heightened and focused sensory awareness. 11. The self and object differentiation remains intact. 12. Unimpaired reality testing. 13. Heightened self-esteem. heightened and focused sensory awareness. Self and object differentiation remains intact throughout the episode, as does reality testing. Finally, a heightened sense of self-esteem is present immediately following the episode. The differences in these two types of aggression can be illustrated by examining the behavior of the domestic cat. When a household cat is cornered or threatened a display of affective aggression is seen: hissing, hair standing on end, dilated pupils, active clawing, and arching back. When the same cat is stalking prey, however, predatory aggression dominates: quiet stalking of the prey, the absence of ritualistic behavior, and focused attention on the target. In humans, predatory aggression is the hallmark of the psychopathic personality, whether it is a primitive act of violence against a stranger or a technically sophisticated act of revenge against a business associate. Affective aggression is more commonly seen during episodes of extreme anger, in persons intoxicated with alcohol or drugs, or in psychiatric patients under the influence of paranoid or persecutory delusions. NEUROCHEMISTRY OF VIOLENCE A variety of neurotransmitter and hormonal influences have been implicated in violence and aggression. Serotonin is of particular interest in the study of violence. Volavka has pointed out that serotonin (5-HT)

7 THEODORE B. FELDMANN 125 exhibits inhibitory control over both affective and predatory aggression (4). Low levels of cerebrospinal fluid (CSF) 5-hydroxy-indole-acetic acid (5-HIAA), a serotonin metabolite, were found in depressed patients who had a history of violent suicide attempts, but not in patients with nonviolent suicide attempts (5). A Finnish study of prison inmates found that violence and impulsivity were associated with low CSF 5-HIAA levels (6). A study of convicted murders also found decreased CSF 5-HIAA levels compared with controls (7). Certain types of stress-related aggression appear to be associated with increased activity in the norepinephrine system. Brown et al found a positive correlation between CSF levels of MHPG, a major metabolite of norepinephrine, and aggression (8). However, MHPG levels did not discriminate between murderers and other offenders, as 5-HIAA levels did. Irritability in response to environmental stressors is thought to be mediated by the norepinephrine system in patients with personality disorders. Norepinephrine has also been found to have a positive correlation with affective aggression and negative correlation with predatory aggression. Dopamine also has a positive correlation to affective aggression but a negative correlation to predatory aggression. Acetylcholine activates both types of aggression. Endocrine and hormonal factors also influence violence (4). Hypoglycemia may elicit irritability, aggression, and confusion these clinical signs are also associated with EEG diffuse slowing, sometimes escalating into paroxysmal activity. Testosterone and other androgens have been implicated in aggressive behavior. Increased levels predispose to heightened aggression; decreased levels raise the threshold for aggressive behavior. Predatory aggression is not androgen dependent. Finally, progesterone and estrogen levels also influence aggression and irritability. Decreased progesterone and estrogen levels coupled with increased prolactin leads to irritative aggression (e.g., PMS). VIOLENCE IN PSYCHIATRIC DISORDERS The connection between psychiatric illness and violence has been controversial. Many mental health advocates minimize the linkage between psychopathology and aggression, pointing out that such studies serve only to further stigmatize those persons with psychiatric illnesses. Monahan has reported that, in general, mental illness accounts for only 3% of violence in American society (9). Certain psychiatric diagnoses, however, are associated with significantly higher rates of violence. Swanson conducted a survey of 10,000 persons, examining violent

8 126 PSYCHIATRIC QUARTERLY TABLE 4 Violent Behavior in the Past Year (Source: Swanson et al., 1990) No Psychiatric Diagnosis 2% Manic-Depressive Illness 11% Depression 12% Schizophrenia 13% Cannabis Abuse/Dependence 19% Alcohol Abuse/Dependence 25% Other Drug Use 35% behavior occurring in the year preceding the survey (10). Rates of violence ranged from 10 to 35%, depending on the nature of the psychiatric condition (see Table 4). In general, the greater the number of psychiatric illnesses a given individual has, the greater his or her risk for violence. When a substance abuse disorder coexists with another psychiatric diagnosis, such as depression, the rate of violence increases by 33% to 50%. The influence of psychiatric illness on violence appears to be greater for women than for men (11). For example, women with a psychiatric diagnosis are 28 times more likely to be convicted of a violent crime than women in the general population. In examining these figures, however, one important caveat should be taken into consideration: the overwhelming majority of persons with mental illness are not dangerous. If a person is not experiencing a psychotic episode, then he or she is no more likely than the average person to be involved in violent acts. The presence of delusions has been thought to increase the risk of violence among psychiatric patients (12). In a comparison of community residents and former psychiatric patients, Link et al found that differences in rates of violence between the two groups were directly related to the presence of psychotic symptoms, particularly threat/control override delusions (13). The connection between delusions and violence, however, is not universally accepted. A recent study followed 1,136 discharged psychiatric patients for one year to assess their risk for violence (14). The results found that neither delusions in general nor threat/control override delusions in particular were associated with higher rates of violent behavior. These findings appear to contradict earlier studies of violence among discharged psychiatric patients. The authors, however, cautioned that their findings do not suggest that delusions are never associated with violence. The presence of delusions may lead to violence in any given

9 THEODORE B. FELDMANN 127 patient, but apparently does not lead to an overall increase in risk of violence during the first year following discharge. VIOLENCE AMONG PATIENTS WITH BIPOLAR DISORDER The connection between bipolar disorder and violence appears to be strongest during acute episodes of illness. Manic patients who displayed violent behavior in the community during the 2 weeks preceding admission had higher rates of violence during the first 3 days of hospitalization (15). Targets of violence were generally random in these cases. Manic patients often become violent when they feel restricted or when limits are set by staff (16). The diagnosis of bipolar disorder may also be a variable correlated with assaultiveness among hospitalized patients, but the correlation may vary as a function of postadmission time. During the first 24 hours of hospitalization, manic patients were more violent than schizophrenic and other patients (17). However, manic patients may respond to treatment faster than schizophrenics thus, violence related to psychosis abates faster in manic patients than in schizophrenic patients (4). Bipolar patients are more likely to be violent when manic than when depressed (18). Schizophrenia and mania were overrepresented among assaultive patients in private hospitals (19). This study also identified a positive correlation between the following symptoms and violence in bipolar patients: conceptual disorganization, auditory hallucinations, unusual thought content, suspiciousness, uncooperativeness, and hostility. Forty-two percent of juvenile offenders assigned to a Texas detention center met DSM-IV criteria for affective disorders (20). Depression was found in 20% of the population and mania in 22%. The majority of the subjects had been arrested for property crimes or assault. The rates of depression and mania in the sample population were significantly higher than those found in community samples of adolescents (8% and 1%, respectively). Not all research has supported an association between assaultiveness and mania assaultive behavior was not present even though agitation was reported more frequently among manic individuals than in patients with other diagnoses (21). This study found the strongest association between dysthymia and violence. Lithium and divalproex were similar in their effectiveness in controlling manic episodes, but divalproex was more effective in the treatment of combined depressive and manic states (22). In patients with

10 128 PSYCHIATRIC QUARTERLY dysphoric mania who displayed hostile, aggressive, or impulsive behavior, divalproex was superior to lithium. Two current studies conducted by the author examine the linkages between psychiatric disorders and violence. The first consists of a study of 419 persons involved in hostage/barricade situations. Over 88% of subjects met DSM-IV criteria for a psychiatric illness; 34% of subjects had affective disorders. Depression accounted for 31% of cases and bipolar disorder for 3% of cases. The affective disorder group had higher rates of violence (including suicide) than other diagnostic groups. Negotiations conducted by police were less successful among the depressed subjects compared to the manic individuals. Assault by the SWAT team was more common in cases involving affective disorders. The second study examines 877 workplace violence offenders. Eightyfive percent of subjects met DSM-IV criteria for a psychiatric disorder, and 21.6% had affective disorders. Depression represented 19.2% of the diagnoses and bipolar disorder 2.4%. Workplace violence offenders with affective disorders were less violent than offenders with Axis II or substance abuse diagnoses. SUMMARY Violence is influenced by a multitude of factors including both biological and psychosocial components. In general, persons with psychiatric disorders are at greater risk to commit acts of violence than individuals without psychopathology. There is considerable variation, however, in the rates of violence among psychiatric patients. Violent behavior is more common among patients with bipolar disorder. The risk of violence is greater during the manic phase of illness. In most cases violence is random and not goal-directed. A specific target of aggression is rare. Early diagnosis and pharmacologic intervention is the most effective means of preventing violence in these patients. REFERENCES 1. Monahan J: Dangerous and violent behavior. Occupational Medicine: State of the Art Reviews 1: , Federal Bureau of Investigation: Uniform Crime Reports. Washington, DC, US Department of Justice, Meloy JR: The Psychopathic Mind: Origins, Dynamics and Treatment. Northvale, NJ, Jason Aronson, 1988, pp

11 THEODORE B. FELDMANN Volavka J: Neurobiology of Violence. Washington, American Psychiatric Press, DC, Asberg M, Traskman L, Thoren P: 5-HIAA in the cerebrospinal fluid: A biochemical suicide predictor? Archives of General Psychiatry 33: , Linnoila M, Virkkunen M, Scheinin M, et al: Low cerebrospinal fluid 5-hydroxyindole acetic acid concentration differentiates impulsive from non-impulsive violent behavior. Life Science 33: , Lidberg L, Tuck JR, Asberg M, et al: Homicide, suicide and CSF 5-HIAA. Acta Psychiatr Scand 71: , Brown GL, Goodwin FK, Ballenger JC, et al: Aggression in humans correlates with cerebrospinal fluid amine metabolites. Psychiatry Research 1: , Monahan J: Mental disorder and violent behavior: Perception and evidence. American Psychologist 47: , Swanson JW, Holzer CE, Ganju VK, et al: Violence and psychiatric disorder in the community: Evidence from the epidemiological catchment area surveys. Hospital and Community Psychiatry 41: , Torrey F. Women, mental illness and violence. Psychiatric News 5, November 19, Junginger J, Parks-Levy J, McGuire L: Delusions and symptom-consistent violence. Psychiatric Services 49: , Link BG, Andrews H, Cullen F: The violent and illegal behavior of mental patients reconsidered. American Sociological Review 57: , Appelbaum PS, Robins PC, Monahan J: Violence and delusions: Data from the MacArthur violence risk assessment study. American Journal of Psychiatry 157: , McNeil DE, Binder RL, Greenfield TK: Predictors of violence in civilly committed acute psychiatric patients. American Journal of Psychiatry 145: , Tardiff K: Characteristics of assaultive patients in private hospitals. American Journal of Psychiatry 141: , Binder RL, McNiel DE: Effects of diagnosis and context on dangerousness. American Journal of Psychiatry 145: , Yesavage JA: Bipolar illness: Correlates of dangerous inpatient behaviour. British Journal of Psychiatry 143: , Tardiff K: Prediction of violence, in Medical Management of the Violent Patient. Edited by Tardiff K, New York, Marcel Dekker, Pliszka SR, Sherman JO, Barrow MV, et al: Affective disorder in juvenile offenders: A preliminary survey. American Journal of Psychiatry 157: , Collins JJ, Bailey SL: Relationship of mood disorders to violence. Journal of Nervous and Mental Disease 178:44, Swann AC: Treatment of aggression in patients with bipolar disorder. Journal of Clinical Psychiatry Monograph 17:2, 18 21, 1999.